Healthcare Provider Details

I. General information

NPI: 1811423569
Provider Name (Legal Business Name): ELLEN MCCORMACK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2017
Last Update Date: 10/27/2021
Certification Date: 10/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 28TH ST
DENVER CO
80205-3003
US

IV. Provider business mailing address

777 BANNOCK ST # MC1923
DENVER CO
80204-4597
US

V. Phone/Fax

Practice location:
  • Phone: 303-602-6333
  • Fax:
Mailing address:
  • Phone: 303-436-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number70543
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0066698
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: